[Senate Hearing 113-897]
[From the U.S. Government Publishing Office]





                                                        S. Hrg. 113-897
 
                      MEDICARE ADVANTAGE: CHANGING
                   NETWORKS AND EFFECTS ON CONSUMERS

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS


                             SECOND SESSION

                               __________

                         HARTFORD, CONNECTICUT

                               __________

                            JANUARY 22, 2014

                               __________

                           Serial No. 113-17

         Printed for the use of the Special Committee on Aging
         
         
         
  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]       
         
         


        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                            ______
 
              U.S. GOVERNMENT PUBLISHING OFFICE 
46-922 PDF             WASHINGTON : 2023
      
        
        
                       SPECIAL COMMITTEE ON AGING

                     BILL NELSON, Florida, Chairman

RON WYDEN, Oregon                    SUSAN M. COLLINS, Maine
ROBERT P. CASEY, JR., Pennsylvania   BOB CORKER, Tennessee
CLAIRE McCASKILL, Missouri           ORRIN G. HATCH, Utah
SHELDON WHITEHOUSE, Rhode Island     MARK KIRK, Illinois
KIRSTEN E. GILLIBRAND, New York      DEAN HELLER, Nevada
JOE MANCHIN III West Virginia        JEFF FLAKE, Arizona
RICHARD BLUMENTHAL, Connecticut      KELLY AYOTTE, New Hampshire
TAMMY BALDWIN, Wisconsin             TIM SCOTT, South Carolina
JOE DONNELLY, Indiana                TED CRUZ, Texas
ELIZABETH WARREN, Massachusetts
                              ----------                              
                  Kim Lipsky, Majority Staff Director
               Priscilla Hanley, Minority Staff Director
               
                         C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Richard Blumenthal, Member of the 
  Committee......................................................     1
Opening Statement of Senator Sheldon Whitehouse, Member of the 
  Committee......................................................     2

                           PANEL OF WITNESSES

Stephanie Kanwit, Principal, Kanwit Healthcare Consulting, and 
  Former Special Counsel, America's Health Insurance Plans.......     4
Brian Biles, M.D., Professor, George Washington University School 
  of Public Health and Health Services and Chair of the 
  Department of Health Services Management and Policy............     6
Judith Stein, Esq., Founder and Executive Director of the Center 
  for Medicare Advocacy..........................................     9
Michael Saffir, M.D., Physiatrist and President, Connecticut 
  State Medical Society..........................................    13
Raymond Welch, M.D., Dermatologist, Rhode Island Dermatology and 
  Laser Medicine.................................................    15

                                APPENDIX
                      Prepared Witness Statements

Stephanie Kanwit, Principal, Kanwit Healthcare Consulting, and 
  Former Special Counsel, America's Health Insurance Plans.......    37
Brian Biles, M.D., Professor, George Washington University School 
  of Public Health and Health Services and Chair of the 
  Department of Health Services Management and Policy............    51
Judith Stein, Esq., Executive Director, Center for Medicare 
  Advocacy.......................................................    58
Michael Saffir, M.D., Physiatrist and President, Connecticut 
  State Medical Society..........................................    63
Raymond Welch, M.D., Dermatologist, Rhode Island Dermatology and 
  Laser Medicine.................................................    67

                       Statements for the Record

George C. Jepsen, Attorney General, State of Connecticut.........    73
Alan F. List, M.D., President and CEO, Frank and Carol Morsani 
  Chair, Moffitt Cancer Center...................................    75
Robert Buccieri, Medicare Beneficiary............................    77


                      MEDICARE ADVANTAGE: CHANGING

                   NETWORKS AND EFFECTS ON CONSUMERS

                              ----------                              


                      WEDNESDAY, JANUARY 22, 2014

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:00 p.m., Room 
2E, Legislative Office Building, 300 Capitol Avenue, Hartford, 
Connecticut, Hon. Richard Blumenthal, Member of the Committee, 
presiding.
    Present: Senators Blumenthal and Whitehouse.
    Also present: Senator Murphy.

                 OPENING STATEMENT OF SENATOR 
          RICHARD BLUMENTHAL, MEMBER OF THE COMMITTEE

    Senator Blumenthal. Thank you everyone for being here.
    For those who may not have been outside and for the record, 
I want to thank Chairman Nelson of the Special Committee on 
Aging. I serve on it, and he has given us permission to be here 
today and to have this field hearing on a topic that I know is 
very, very important to the State of Connecticut and to the 
State of Rhode Island.
    I want to welcome my colleague, Senator Murphy and Senator 
Sheldon Whitehouse of Rhode Island.
    We have a panel of five really outstanding witnesses today, 
and I want to welcome them all here, especially those who made 
it to Hartford from Washington and Rhode Island.
    We think it is important to hold this hearing for a number 
of reasons. While we are seeing insurers decide to offer 
narrower networks, in an intent to reduce costs across the 
country, these decisions have a very dramatic impact here in 
Connecticut, where 2,250 providers were terminated with 
virtually no notice, and that termination affected about 61,000 
patients under the Medicare Advantage program, about 43 percent 
of all the patients who have Medicare Advantage plans.
    We are here today to hear from the folks who can shed some 
light on what these sudden terminations mean for patients, in 
the midst of deciding whether they stay with their Medicare 
Advantage plans, and what options are available to them and 
what can be done to prevent this kind of abusive and, very 
likely, illegal action from happening again.
    Right now, the terminations have been enjoined. There will 
be an appellate argument next week.
    I have joined in that argument as a friend of the court in 
a brief that I filed because I feel so strongly, as do my 
colleagues, about the importance of this issue to people in 
Connecticut and people throughout the country.
    I do not know whether Senator Murphy or Senator Whitehouse 
have any additional statements that they would like to make.
    Senator Whitehouse?

                 OPENING STATEMENT OF SENATOR 
          SHELDON WHITEHOUSE, MEMBER OF THE COMMITTEE

    Senator Whitehouse. No. I just want to thank you both for 
your hospitality. It is good to be here in your state. Rhode 
Island, your eastern neighbor, has the same predicament with 
United.
    I am pleased to serve on the Aging Committee with Senator 
Blumenthal and on the Health, Education, Labor and Pensions 
Committee with Senator Murphy, and since both of those 
committees have a keen interest in this issue, it is a delight 
to be here.
    They are also terrific colleagues, and, on this issue, 
people talk about Washington and who is a showhorse and who is 
a workhorse. You have two workhorses in the Connecticut Senate 
on health care issues, so it is a great honor for me to be here 
with both of them.
    Senator Blumenthal. Thank you.
    Senator Murphy?
    Senator Murphy. Thank you, Senator Blumenthal.
    I just wanted to thank you for allowing me, as a non-Aging 
Committee member, to sit in on this hearing, but, as a member 
of the Health, Education, Labor and Pensions Committee, this is 
obviously an issue that we have jurisdiction over as well, so, 
really excited to be here.
    This is a great panel, and I think what I hope that we will 
do here today is to examine both the immediate issue, which is 
of concern to thousands of Connecticut and Rhode Island 
residents, but also talk about the bigger picture because we do 
live in a world in which we are going to see the contraction 
and sometimes expansion, but certainly always change, in 
provider networks, and we have just got to sit together and 
figure out the best way to do that from a cost perspective, 
from a patient protection perspective and from a quality 
perspective.
    Senator Blumenthal. I should say that both Senator Murphy 
and Senator Whitehouse, along with myself, are members of a 
task force on health care delivery, which we have organized to 
look at these issues.
    Sheldon Whitehouse has been an advocate on these issues 
from well before I was in the Senate, and I want to thank him 
particularly for his leadership.
    Let me introduce the witnesses that we have here today, 
with the first panel before us.
    Stephanie Kanwit is a Senior Health Care Consultant in 
Washington, DC, who currently serves as Special Counsel to 
America's Health Insurance Plans, AHIP, and the Pharmaceutical 
Care Management Association.
    Prior to that, she served as General Counsel for AHIP and 
three stints as a partner in private law firms in DC and 
Chicago--Chadwell and Kayser, Lamet Kanwit and Davis in 
Chicago, Epstein Becker and Green in Washington, and she also 
has served as Vice President of Health Litigation at Aetna here 
in Hartford.
    Brian Biles comes to us from George Washington University 
School of Public Health and Health Service, where he is 
professor and Chair of the Department of Health Services 
Management and Policy.
    Prior to his current position, he was Senior Vice President 
of the Commonwealth Fund and served for seven years as Staff 
Director of the Subcommittee on Health in the Committee on Ways 
and Means of the United States House of Representatives. He 
worked on the Health Subcommittees chaired by Representative 
Henry Waxman and Senator Edward Kennedy, two great heroes in 
health care advocacy, and he has authored numerous papers. I am 
not going to go through the entire list, but he has a master's 
degree in public health from Johns Hopkins University, and he 
received his doctor of medicine and bachelor of arts degrees 
with honors from the University of Kansas.
    I am told--I hope, reliably--that your wife is from 
Connecticut.
    Judith Stein, another hero, is the founder and Executive 
Director of the Center for Medicare Advocacy.
    Anybody who has been in this building, anybody who has any 
experience in health care in Connecticut knows of her extensive 
experience in developing and administering Medicare advocacy 
projects. She has been a champion of Medicare beneficiaries, 
producing educational materials, teaching and consulting.
    She has been the lead counsel or co-counsel in numerous 
Federal class action and individual cases, challenging improper 
Medicare policies and denials, and I have been privileged to 
join with her when I served as attorney general in some of 
those actions.
    She also was a delegate to the 2005 White House Conference 
on Aging and received the Connecticut Commission on Aging 
Agewise Advocate Award in 2007.
    She graduated cum laude from Williams College and received 
her law degree with honors from Catholic University School of 
Law.
    Dr. Michael Saffir is a practicing psychiatrist, 
specializing in physical medicine, rehabilitation and pain 
management. He practices at the Orthopedic Specialty group in 
Fairfield, Connecticut and is the Division Chief of Medicine 
and Rehabilitation in the Department of Medicine at St. 
Vincent's Medical Center in Bridgeport. He is also President of 
the Connecticut State Medical Society.
    Did I get your specialty wrong?
    Dr. Saffir. Physiatrist. Physical medicine rehabilitation.
    Senator Blumenthal. Okay. Thank you.
    I am going to ask Senator Whitehouse to introduce Dr. 
Welch, who is from Rhode Island.
    Senator Whitehouse. It is my great honor to have the 
opportunity to introduce Dr. Raymond Welch, who is a practicing 
physician in Rhode Island in the field of dermatology. He has 
been practicing in the Providence area for 28 years, focusing 
his work on the diagnosis and treatment of skin cancer. He is 
also an Assistant Clinical Professor at the Warren Alpert 
School of Medicine at Brown University.
    He has a long record of recognitions. He was elected in 
2007 to the Noah Worcester Dermatological Society. He is a 
member of the New England Dermatology Society, the Rhode Island 
Dermatology Society and the American Society of Laser Medicine 
and Surgery.
    He is a graduate of Albany Medical College in New York, 
served his residency at Albany Medical Center Hospital and 
completed his dermatology residence at Duke University Medical 
Center.
    We are delighted that he took the trouble to come from 
Rhode Island to be here and to share his perspective.
    Thank you very much.
    Senator Blumenthal. Thank you.
    Why don't we----
    Senator Whitehouse. Should we get into the record now about 
United and whether their being here or not here, they were at 
least invited?
    Senator Blumenthal. Sheldon Whitehouse, Senator Whitehouse, 
makes the excellent point that I want to put on the record that 
UnitedHealthcare Group was invited. I did invite them to this 
hearing. They have declined to appear.
    Why don't we begin going from my left to right?
    We will begin with you, Ms. Kanwit.

           STATEMENT OF STEPHANIE KANWIT, PRINCIPAL,

            KANWIT HEALTHCARE CONSULTING, AND FORMER

       SPECIAL COUNSEL, AMERICA'S HEALTH INSURANCE PLANS

    Ms. Kanwit. Thank you. Good afternoon, Chairman Blumenthal 
and members of the Committee.
    I am honored to be here in my home State of Connecticut. I 
am Stephanie Kanwit, and I am testifying today on behalf of 
America's Health Insurance Plans, known as AHIP.
    I appreciate this opportunity to testify on issues 
surrounding provider networks in the Medicare Advantage Program 
and the strategies our members are employing in this area to 
hold down costs and, at the same time, improve value for their 
enrollees.
    Health plans in the Medicare Advantage, MA, program have a 
strong track record of offering high-quality coverage options 
with innovative programs and services for both seniors and 
individuals with disabilities. As emphasized in our written 
testimony, one strategy that plans are pioneering involves the 
use of high-value provider networks along with programs that 
encourage enrollees to obtain care from providers who have 
demonstrated, based on performance, metrics, their ability to 
deliver high-quality and cost-effective care, and those are the 
keys.
    Our written testimony focuses on three broad areas:
    First, background on the MA program, including the value it 
delivers to beneficiaries.
    Second, as the MA program faces a future of severe 
underfunding, we discuss the opportunity for these high-value 
provider networks I mentioned to preserve benefits and mitigate 
the cost impact on the MA beneficiaries.
    Third, we focus on the leadership role that health plans 
are playing in advancing delivery system reforms, so, just some 
quick background. More than 14.5 million seniors in the United 
States and people with disabilities, about 28 percent of the 
Medicare population, currently are enrolled in MA plans.
    Senator Whitehouse, that is higher in Rhode Island. It is 
about 35 percent.
    Why? They value the care coordination and disease 
management activities, improved quality of care and innovative 
services and benefits that are available through these plans.
    Now MA plans offer a different approach to health care 
delivery than beneficiaries experience under the regular 
Medicare fee-for-service, FFS, program. They have developed 
systems of coordinated care--key word, coordinated--for 
ensuring that beneficiaries receive health care services on a 
timely basis while also emphasizing prevention and providing 
access to disease management services for chronic conditions. 
These coordinated services and systems provide for the seamless 
delivery of health care across the continuum.
    We are talking physician services, hospital care, 
prescription drugs and other health care services, all 
integrated and delivered through an organized system. The 
overriding purpose is to prevent illness, manage chronic 
conditions, improve health status and swiftly treat medical 
conditions as they occur rather than waiting until they have 
advanced to a more serious state.
    The key question is this: Have they been successful?
    The answer is yes.
    First, we know that because survey findings show that MA 
enrollees are highly, highly satisfied with their health 
plans--90 percent, plus.
    Secondly, we know that because research findings 
consistently demonstrate that MA plans have better health 
outcomes and beneficiaries receive higher-quality care than 
their counterparts in the Medicare FFS program.
    The value that MA enrollees receive through their plans can 
also be seen in the additional services and benefits that are 
offered--services and benefits that are not offered in the 
Medicare fee-for-service program. Although these vary from plan 
to plan, these typically include case management, disease 
management, wellness and prevention programs, prescription drug 
management tools, nurse help hotlines, and vision, hearing and 
dental benefits.
    MA plans also protect beneficiaries from high out-of-pocket 
costs, and this year, in 2014, all MA plans are going to offer 
an out-of-pocket maximum for beneficiary costs.
    Another important feature of MA programs is enrollees have 
strong consumer protections, and this includes extensive 
network adequacy standards, which ensure that MA enrollees have 
access to all provider types, including primary care physician 
as well as specialists within a reasonable time and distance 
from their homes.
    CMS works with MA plans when network changes are made to 
ensure that beneficiaries continue to have access to the 
benefits and services they need, but we are deeply concerned 
that the MA program is facing a future of severe underfunding 
that jeopardizes the stability of these plans.
    The Affordable Care Act, the health reform law, ACA, 
imposes more than $200 billion in funding cuts on MA over a 10-
year program. Through last month, December of 2013, only 10 
percent of those cuts had gone into effect, but another 35 
percent will be phased in between 2014 and 2016, so they are 
back-loaded.
    On top of those cuts, MA enrollees are impacted by the new 
ACA health insurance tax that went into effect on January 1st, 
2014.
    Now facing such a challenging budgetary environment, MA 
plans are working hard to maintain access to high-value 
benefits and services for their enrollees, but we have serious 
concerns, as I mentioned, about the underfunding of the MA 
program as ACA cuts are phased in at an increasingly faster 
rate over the next several years.
    The need is greater now than ever before for innovations 
that deliver increased values to beneficiaries with 
increasingly limited resources that are available to support 
the MA program.
    In response to that challenge, MA plans are working hard to 
preserve benefits and improve quality for enrollees by 
developing what I mentioned previously--high-value provider 
networks.
    What are high-value provider networks?
    Health plans typically develop these networks using 
performance metrics, with a strong emphasis on quality 
criteria, to select high-performing, cost-effective providers, 
using widely recognized, evidence-based measures of provider 
performance such as those endorsed by the National Quality 
Forum. Health plans can create select or tiered networks of 
providers comprised of clinicians and facilities that score 
well on measures of efficiency and quality.
    Now a central goal of these high-value provider networks, 
including those offered by MA plans, is to improve health care 
quality and efficiency through ongoing evaluation of provider 
performance, assessment of resource use, referrals to other 
high-performing providers and the exchange of health 
information with the plan and other providers caring for the 
same patients; so, that kind of coordination.
    Critically, these high-value provider networks create 
strong incentives for providers to offer competitive prices in 
response to the increased number of patients they gain as a 
member of the network, and this, in turn, enables the health 
plans to deliver substantial savings to their enrollees in 
addition to connecting them to high-quality providers.
    I want to thank you for considering our views on these 
important issues.
    We look forward to working with Congress to strengthen and 
preserve the MA program, and, to achieve this goal, we urge you 
to help ensure that funding for the MA program is stabilized 
and that MA plans have the flexibility to advance high-value 
provider networks and other innovations that promote quality 
and efficiency for Medicare beneficiaries.
    Thank you.
    Senator Blumenthal. Thank you very much.
    Professor.

       STATEMENT OF BRIAN BILES, M.D., PROFESSOR, GEORGE

       WASHINGTON UNIVERSITY SCHOOL OF PUBLIC HEALTH AND

         HEALTH SERVICES AND CHAIR OF THE DEPARTMENT OF

             HEALTH SERVICES MANAGEMENT AND POLICY

    Dr. Biles. Thank you very much, Senator Blumenthal, Senator 
Whitehouse, Senator Murphy, for convening this hearing on what 
is really a new and very important issue.
    I would note that my wife, in fact, did grow up in Easton, 
where her great grandparents moved from Slovakia in the 1880s 
to take over some of the farmland in that area.
    Senator Blumenthal. Not a lot of farmland left in Easton.
    Dr. Biles. Not a lot. It is all--as you well know Easton.
    The focus of this hearing--I think, it could be termed 
network narrowing of physicians by UnitedHealthcare's Medicare 
Advantage plans--is important now both in Connecticut and Rhode 
Island, and nationwide, and it is certainly to become more 
important in the years ahead, which I think is why this is such 
an important discussion. New Medicare policies to address the 
situation will be important, particularly to elderly and 
disabled beneficiaries.
    The focus of today's hearing is United Healthcare's recent 
action, and a special concern regarding United's announcement 
is when it occurred and particularly occurred after the 
beginning of the Medicare beneficiary open enrollment period 
that began on October 15th and ran until December 7th.
    I think if I were to focus on one area it is the lack of 
advance notice. I do not know whether it is too strong to say 
this is an example of bait and switch, but clearly, elderly, 
disabled beneficiaries went through an open enrollment period 
before all of this was clearly understood and they could take 
action in response.
    The term, network narrowing, has been described as 
reduction in the number of physicians participating in managed 
care plans, and I will focus today in five areas.
    First, the point is that Medicare beneficiaries always have 
the option to be covered by traditional Medicare, which has the 
broadest network, of course, of any health plan and any health 
insurance program the country.
    Second, again, the managed care network narrowing that we 
see in Connecticut is neither new nor limited to Medicare.
    Three, Medicare--and this is a particularly important 
issue--has been paying private plans more than it costs in 
traditional Medicare fee-for-service for beneficiaries enrolled 
in the plan. Our research found that extra payments--payments 
in addition to costs in Medicare, traditional Medicare--in 2009 
averaged 14 percent, $1,100 per enrollee and a total of over 
$12 billion.
    Fourth, as payments are reduced, the plans with policies 
have been mentioned in the ACA. To reduce these extra 
overpayments, it is clear that plans will accommodate and adopt 
more efficient and effective ways to provide care, including 
physician networks.
    My fifth point then is policies that protect Medicare 
beneficiaries, as plans develop narrow networks, are important 
at this time.
    To elaborate a bit, the most important point relative to 
changes is the underlying fact that beneficiaries must always 
choose to be covered by, and receive care from, plans rather 
than the traditional Medicare program.
    We have studies from MedPAC, which indicate that Medicare 
beneficiaries in traditional Medicare have very broad access to 
physicians and are quite satisfied with that care. One study 
found that in spite of the general shortage of primary care 
physicians, less than two percent of Medicare beneficiaries in 
traditional Medicare reported a major problem finding a primary 
care physician.
    There is--if you want to view it as--a fallback of a safety 
net, and that is where almost 75 percent of the Medicare 
beneficiaries are today.
    The second point, of course, is that managed care plans 
with limited or narrow networks are neither new nor limited to 
Medicare.
    If we go all the way back to the 1970s, President Nixon and 
Senator Kennedy developed the Medicare Assistance Act. That was 
all based on Kaiser Permanente, and the entire premise was that 
plans would have narrow networks. They could be efficient, they 
could manage for care, and as a result, could provide care both 
in a less expensive, but also more effective, manner.
    We have seen over the years, particularly in the 1990s, on 
one hand, a national movement toward plans with narrower 
networks followed by a response, and then as the recession 
eased, the economy became more robust and employers moved to 
much broader networks.
    If we then turn to the next point, which is that plans have 
been paid more in traditional Medicare over the past, since 
2006. We find that Medicare Advantage, the Medicare 
Modernization Act, the prescription drug bill in 2003, 
implemented in 2006, paid all plans in the Nation more than 
costs in fee-for-service in the same county, and, again, the 
average was 14 percent, $1,100 in 2009.
    The fourth point, of course, is in the ACA, as a general 
effort to reduce costs to Medicare and in health care, that 
included policies to reduce payments to hospitals and other 
providers, these extra additional payments to Medicare 
Advantage plans were gradually phased out through the year 
2017, and our modeling indicates that by 2017 plans will be 
paid an average of 101 percent of costs in the same county.
    History and current plan practices suggest that changes by 
Medicare Advantage plans to accommodate this gradual phase-down 
of these extra payments will likely include some network 
narrowing, so I think that is built into the system. I think it 
is expected.
    I think the most important point of today's hearing is that 
since this is a new trend or event in Medicare, there is a need 
for new policies, particularly advance notice to beneficiaries.
    Particularly, there is something called the advance notice 
of changes, which is due on September 30th, that right now only 
focuses on benefits and out-of-pocket costs and does not 
include any mention of changes in networks, so, if any changes 
in networks were included in that September 30th, notice with 
the open enrollment period running from October 15th to 
December 7th, I think that would give beneficiaries the notice 
they need and the time to decide a new plan--for example, in 
New Haven, the Aetna plan--or perhaps to shift back to 
traditional Medicare.
    We might also note if you pick that December 30th date, 
then plans would be negotiating with physicians, and I do think 
there is both not only the beneficiary point of view but the 
physician point of view, but that plans need to engage in that 
discussion and negotiation then much earlier in the year in 
order to provide the adequate notice to beneficiaries.
    I think in conclusion that there is a broad background to 
the issue that suggests that network narrowing is reasonable--
it has certainly been historically understood and accepted--but 
that as we move from these, again, $1,100 a year extra payments 
to plans to something closer to costs in traditional Medicare, 
that new policies dealing mostly and foremost with 
beneficiaries, but also with physicians, are needed at this 
time.
    Thank you very much.
    Senator Blumenthal. Thank you very much.
    Judith Stein.

                STATEMENT OF JUDITH STEIN, ESQ.,

               FOUNDER AND EXECUTIVE DIRECTOR OF

                THE CENTER FOR MEDICARE ADVOCACY

    Ms. Stein. Thank you very much for holding this hearing, 
Senator Blumenthal, and for coming back home, and the same to 
Senator Murphy.
    I mentioned to Senator Whitehouse that in addition to 
having longstanding alliances with Senators Murphy and 
Blumenthal, I have a family of my daughter, son-in-law and 
children in Providence, Rhode Island, both of who went to 
Brown, so it is really wonderful to have you here today.
    Senator Whitehouse. Which we take terribly seriously, so 
thank you for mentioning that.
    Ms. Stein. As you know, I am the founder and Executive 
Director of the Center for Medicare Advocacy, which I founded 
in 1986, after having done elder and health care law at 
Connecticut Legal Services for 10 years.
    The center is a private, nonprofit organization. I think it 
is the only organization in the country that can boast it is 
based on the quiet corner of Connecticut and has a satellite 
office in Washington, D.C. We are in Mansfield, Connecticut, 
and we serve the entire state and also hear from people, and 
try and advocate as best we can, from those all over the 
country.
    The center provides education and legal assistance to 
advance fair access to Medicare and quality health care for 
Medicare beneficiaries throughout the country and Connecticut. 
We represent Medicare beneficiaries, respond to over 7,000 
calls and e-mails annually, host web sites, webinars, publish a 
weekly electronic and quarterly print newsletter, and provide 
materials, education and expert support for Connecticut's 
CHOICES program.
    I am also proudly a member of the executive committee of 
the Connecticut Elder Action Network formed and hosted by the 
Connecticut Commission on Aging.
    We are an unusual organization in the country in that there 
are not too many of us who represent Medicare beneficiaries, 
and, as a consequence, we also formed and host the National 
Medicare Advocates Alliance, where some few dozen of us meet 
regularly, and the center provides issue briefs to keep people 
abreast of Medicare issues and how to help low and middle-
income, chronically ill, elder and disabled people.
    As you know and as the reason for our hearing today, in 
2013, UnitedHealthcare jettisoned approximately 2,250 providers 
and health care facilities from its Connecticut Medicare 
Advantage network--2,250. That is a huge number, particularly 
in this small state--about one physician or hospital or nursing 
home or other health care provider lost for every 27 people in 
the United network in the state and for every 260 Medicare 
Connecticut beneficiaries. Neither physicians nor Medicare 
patients were given adequate notice of this extraordinary 
decision.
    As the 2013 Medicare enrollment period and year came to a 
close, many older and disabled people enrolled in a 
UnitedHealthcare Medicare Advantage plan learned that their 
doctors or local hospital would not be available to them in 
United's reduced Medicare Advantage network in 2014.
    We began to receive calls at the center from people who had 
heard this news and were frightened, from our friends at the 
Connecticut Medical Society, from our friends in all the 
offices of our very fine congressional delegation.
    On December 7th, I presented at a meeting held by Rosa 
DeLauro, Congresswoman from the Greater New Haven area in 
Wallingford. When we had a Q&A, about 25 percent, maybe 30, of 
the questions asked by the 150 people on Medicare in the 
audience were about their UnitedHealthcare problems.
    Many others did not learn until after the new year.
    Others will not learn--and this is very important--until 
they seek medical care in 2014. Only then will they find that 
their doctor or other health care provider is no longer in 
their Medicare plan.
    In fact, we have been asked why CMS is not hearing about 
this problem, and I think the answer is two-fold.
    How would people know to contact CMS? Who is and what is 
CMS from the point of view of the older and disabled people who 
rely on Medicare, and their families? How do they know where to 
call? I can tell you 1-800-MEDICARE is not the place.
    Secondly, as I indicated and as others have noted, many, 
many people will not know about this until they seek medical 
assistance into the year. That is when we know, historically, 
we find people calling us about Medicare Advantage and Medicare 
regularly.
    Many people think that Medicare Advantage means that they 
have an advantage to their regular Medicare, that it is 
something on top of their Medicare.
    Under ordinary circumstances, we often get calls after 
February or March from people who cannot get health care from 
their traditional doctor.
    One client of ours and his family learned about the United 
network cut only when health care was urgently needed. Susan W. 
called the Center for Medicare Advocacy on behalf of her 
parents who are both in their 80s.
    He had a stroke in 2013, with bleeding in his brain. He was 
helicoptered from his local hospital to Yale--New Haven 
Hospital due to the complexity of his condition. Now he is 
finding in the middle of his care that his medical and 
rehabilitation needs are severely limited and further 
complicated by the United Medicare Advantage network cuts.
    His longtime primary care doctor is no longer in-network, 
and I echo the comments of the good doctors--that that is the 
relationship that matters to people.
    His local hospital is no longer in United's Medicare 
Advantage network. He must travel farther to another unknown 
hospital, farther from his elderly wife, and find a new doctor 
in the midst of getting care for a stroke.
    Most importantly, he cannot obtain the nursing care or 
rehabilitation he needs at the nursing home closest to his wife 
and community since it, too, has been cut from United's 
Medicare Advantage plan.
    As with many Medicare beneficiaries, Mr. W has long been in 
traditional Medicare with supplemental Medigap coverage, but he 
switched to United's Medicare Advantage plan in 2011, like my 
uncle, because it was less expensive. This worked until he 
became ill and United exercised its business prerogative to 
severely reduce providers from its Medicare Advantage network.
    We know we will hear at the center from many other people 
like Mr. W and his daughter as the year proceeds and they need 
health care, but their providers, their doctor, their hospital, 
their nursing home, in some instances, their home care agency 
are found to no longer be in the Medicare Advantage network.
    United's health care actions would be bold in the private 
health insurance market. They should not be tolerated in the 
public Medicare arena. All Medicare Advantage plans, including 
United, as Professor Biles just testified, are paid more--
more--by taxpayers than it would cost to provide the same 
coverage in traditional Medicare.
    While I respect my colleague from AHIP, I have yet, over my 
30-plus decades of doing this work, to find one of these plans 
regularly providing coordinated care. In fact, not only has my 
92-year-old uncle just had terrible problems with his Medicare 
Advantage plan, with no coordination of care, but we often find 
that, despite the public funding being more than that which 
would be necessary for people getting the same care in 
traditional Medicare, Medicare Advantage plans often provide 
less when people are truly ill.
    United owes its Medicare enrollees and providers at least 
timely notice and a fair remedy when significant network 
reductions like these are planned. It owes its Medicare 
enrollees and taxpayers a truly adequate array of providers 
when it is receiving public funds--robust payments. It should 
not be able to enroll Medicare beneficiaries one year only to 
decimate its network the next.
    What protections can be put in place?
    First, for current United enrollees like Mr. W, who have 
been hurt by provider cuts, they should receive help. Further 
Congress should act so that such severe network reductions do 
not happen in the future. Accordingly, the Center for Medicare 
Advocacy recommends the following:
    First, to protect current UnitedHealthcare Medicare 
Advantage enrollees--and we know this is happening in other 
states; New York, Rhode Island, Florida--require 
UnitedHealthcare, because it is receiving robust public 
funding, to pay the in-network rate on behalf of individuals 
such as our client, Mr. W., who cannot find the quality care 
they anticipated in-network.
    Second, provide a special enrollment period for 
UnitedHealthcare Medicare Advantage enrollees so that they can 
either change to another Medicare Advantage plan or reenter 
traditional Medicare and receive the care from all of the 
networks available to them.
    Third, require UnitedHealthcare to provide quality 
transition services to enrollees such as Mr. W., who are in the 
middle of treatment, so that they are--and also, the gentleman 
who testified--spoke to the press this morning--so that they 
can limit the disruption of their health care. That gentleman 
and Mr. W should be able to continue their care with the 
providers they know and who have been treating their very 
desperate medical situations.
    Secondly, how can we protect future Medicare Advantage 
enrollees from what we are hearing are expected future network 
cuts because the plans will no longer be getting 14 percent 
more? That is what ACA did. It started to scale back paying 14 
percent more to private plans to be in the system.
    Now they can be in the system, but, why should taxpayers 
and all Medicare enrollees be paying what was about $150 
billion over 10 years additional Medicare Advantage plans than 
would be necessary in traditional Medicare?
    Require Medicare Advantage plans to provide notice, at 
least, I said, 60 days, but the notice that Professor Biles 
suggested in the ANOC, the notice that goes out, of change, on 
September 30th would also do, when more than a certain 
percentage of providers are to be cut from a Medicare Advantage 
plan--significant advance notice prior to the beginning of the 
enrollment period on October 15th.
    Review the definition of an adequate Medicare Advantage 
network, to ensure all necessary services are available within 
a truly reasonable geographic area. Norwalk, as we know her in 
Connecticut, is not truly a reasonable geographic area for a 
gentleman with end-stage renal disease to get to the care he 
needs when he lives in Bridgeport.
    Limit the percentage of each kind of provider a Medicare 
Advantage plan may cut from its network.
    Require Medicare Advantage plans to pay as if an enrollee's 
provider was in-network if the plan is determined by CMS to 
have unreasonably reduced its Medicare Advantage providers.
    Provide a special enrollment period for Medicare Advantage 
enrollees to change Medicare Advantage plans or reenter 
traditional Medicare if their plan is determined to have 
unreasonably reduced its provider network.
    Importantly, level the playing field between the two 
Medicare models. For example, include a prescription drug 
benefit in traditional Medicare and identify other incentives 
in the Medicare Advantage program that entice beneficiaries to 
migrate from traditional Medicare to Medicare Advantage, and 
these were really put in place in the law that was passed in 
2003.
    Retain reasonably priced first-dollar Medigap coverage. I 
know this will be before you, Senators, in budget cuts that you 
will be looking at, and there is this notion that people should 
buy Medigap coverage but pay out of pocket before it comes into 
effect. This will further push people to Medicare Advantage.
    As is the case in Connecticut and some other states, make 
it a Federal requirement that Medigap insurance offer 
enrollment. Wider access to Medigap will give Medicare 
Advantage enrollees more flexibility to return to traditional 
Medicare if their Advantage plan no longer meets their 
healthcare needs.
    In conclusion, Connecticut's older and disabled community, 
and our Nation's older and disabled community, deserve better 
treatment than they have received from UnitedHealthcare's 
Medicare Advantage plan. This kind of behavior should not 
happen again, and Medicare beneficiaries caught in this year's 
dramatic network cuts should be helped.
    Thank you for holding this hearing and for giving me the 
opportunity to testify.
    Please let me know if the Center for Medicare Advocacy can 
do anything further to help.
    Senator Blumenthal. Thank you very, very much.
    I want to assure, by the way, all the witnesses that your 
full statements will be in the record. We are going to make 
them a part of the record, without objection.
    Let me turn now to Dr. Saffir.

        STATEMENT OF MICHAEL SAFFIR, M.D., PHYSIATRIST 
        AND PRESIDENT, CONNECTICUT STATE MEDICAL SOCIETY

    Dr. Saffir. Thank you, Senator Blumenthal and Senator 
Whitehouse.
    I would like to commend you, sir, on the recommendations 
that you have put together. They are very pointed and 
successful.
    Good morning. I am Dr. Saffir. I am board-certified 
physiatrist in pain and sports medicine with the Orthopedic 
Specialty Group in Fairfield. I am the President for the 
Connecticut State Medical Society, representing more than 6,000 
practicing physicians and physicians-in-training in the State.
    I received my medical degree from the State University at 
Downstate Medical Center and completed my residency, training 
and fellowship in neuromuscular diseases and electrodiagnostics 
at the Rusk Institute, NY University.
    In addition to my practice, I serve on the Connecticut 
State Worker's Compensation Commission and Medical Advisory 
Committee, where I helped to develop the current attorney-
physician guidelines, insurance payer-physician guidelines, 
treatment guidelines and an RVU-based fee schedule.
    I am also a member of the Connecticut Prescription 
Monitoring Program.
    United's abrupt, significant cuts to its Medicare Advantage 
program in Connecticut are deeply concerning for both patients 
and physicians. United's actions will have significant negative 
effects on the physician-patient relationship, the patient 
access to care and continuity of care for Medicare 
beneficiaries--a vulnerable population with complex medical 
needs, including many with chronic conditions and disabilities 
that limit mobility.
    When UnitedHealthcare decided to drop the physicians in 
Connecticut from its Medicare Advantage plan, they did it in a 
way that seemed to maximize confusion for patients and doctors.
    I would like to let you know that we did ask directly to 
United. We actually had some of their senior medical directors 
fly into Connecticut to talk to us, and we were told that there 
was no cause; it was just a contract; it was not based on 
quality.
    In fact, the United Medicare Advantage plan has an advisory 
panel with physicians. Most of them were unaware that this 
process is going forward, and you would think that if you were 
making a medically based decision that your advisory panel 
would be involved, so many of them stepped down.
    The physician terminations letters were sent by bulk mail 
in early October. Some received multiple letters indicating 
termination. Other doctors had no letter at all but found out 
by going to the web site and finding that the names had been 
removed from the provider directory.
    Physicians who actually received a letter were given no 
reason for termination, which made it difficult to appeal.
    Phone contact with United staff was challenging, as well as 
looking in the online directory.
    Both patients and physicians had problems determining 
network participation. Terminated physicians were listed as 
remaining in-network. Physicians who had not received a letter 
were listed as dropped, and many physicians received some 
verbal assurance, but no written confirmation was provided, 
adding to the confusion.
    United made those physician cuts just before the 2013 open 
enrollment period began on October 15th, and, as was 
highlighted here earlier, patients are required to choose a 
plan during that period, and once selected they are locked into 
that plan without other options. United failed to notify many 
patients of the network changes until mid-November, halfway 
through the open enrollment period.
    From a physician care perspective, United's actions have 
been extremely disruptive. As physicians, we counsel our 
patients about health based on the most accurate and up-to-date 
clinical information. It is difficult to provide similar 
counseling when patients ask questions about whether or not we 
would be able to continue treatment and what the continuity of 
care would be. There was a lack of accuracy and timeliness of 
United's information for them to make decisions.
    Many Connecticut State Medical Society, CSMS, members have 
shared their stories of patients who were confused and upset by 
the changes, because United gave patients no reason for the 
network changes, some patients were worried that the doctors 
may have done something wrong.
    Most recently, United patients have received letters saying 
that they can switch to another doctor for their care, but when 
the patients call this doctor's office they are told they 
cannot be seen or will have to wait weeks or months for an 
appointment.
    Why? United never bothered to ask those listed doctors if 
there was any room left in the patient panels or if they were 
able to accept Medicare patients.
    Throughout this process, the Center for Medicare and 
Medicaid Services, CMS--their lack of oversight and enforcement 
has been disappointing. Simply regurgitating that United played 
by the rules is not enough.
    A common-sense review of travel time and distances 
requirements for the elderly and medically vulnerable patients 
clearly showed that existing guidelines are unrealistic, even 
dangerous.
    Following a 90-day notice guideline does not help patients 
or physicians when that notice was provided in a disorganized 
and incomplete manner. Even more critical, CMS did not seem to 
consider the 90-day notice ran through the open enrollment 
period. Physicians had to make choices for their 2014 health 
care without knowing whether their doctors would be able to 
take care of them.
    Even more, for complicated patients with multiple medical 
conditions, they would have to see different physicians for 
these conditions and decide which physicians they would go with 
and which plan.
    To calculate these decisions were challenging and 
difficult. No patient should have to make that choice.
    Many of our members have had patients ask whether they 
could pay a little extra and stay with the doctor they know and 
trust. Patients were horrified to learn that their doctor--it 
was not a matter of a few dollars, but since there were no out-
of-network benefits in the Medicare Advantage plans, they would 
have to pay the full cost. No patient should have to make that 
choice.
    This is truly a watershed moment. United's actions have 
clearly shown that they place a higher priority on maximizing 
profit than maximizing their members' health.
    Congress needs to recognize what is occurring here in 
Connecticut and across the country, in neighboring states like 
Rhode Island, and have patients have better choices when they 
are going into the open enrollment period.
    I would advocate for that beneficiary notice that Professor 
Biles talked about as being an intelligent option.
    The solution is simple. Patients' access to care needs to 
be protected and maintained for this most vulnerable 
population.
    United needs to be held accountable for its lack of clarity 
and transparency in this process and should demonstrate that 
its actions do not jeopardize access to care and actual 
provision of care to patients.
    CMS should provide a common-sense oversight of United and 
not simply accept the insurer's word that the networks are 
adequate.
    What we would like to see happen is that improvements in 
oversight and policing occur and that changes in the law or 
regulations that CMS applies to these Medicare Advantage plans 
are implemented, and we look forward to working with you on it.
    Senator Blumenthal. Thank you.
    Dr. Welch.

       STATEMENT OF RAYMOND WELCH, M.D., DERMATOLOGIST, 
          RHODE ISLAND DERMATOLOGY AND LASER MEDICINE

    Dr. Welch. Senator Whitehouse, Senator Blumenthal and 
Senator Murphy--did he leave?
    Senator Blumenthal. Senator Murphy had another commitment 
that he had to attend.
    Dr. Welch. I see.
    Ladies and gentlemen, good afternoon. When I was asked to 
speak, I worried that perhaps I would be inadequate to address 
the policy issues. Thankfully, I do not have to do that. I 
could not possibly have said anything that addresses my 
concerns on a nationwide and Federal Medicare scale than what 
has been said.
    What I can do as a practicing physician is address the 
personal side of this. I may add two additional things.
    I want to take issue with the idea that the doctors that 
were terminated were terminated because of any inadequacy in 
their art or science.
    Also, I would like to address the idea that 
UnitedHealthcare takes care of patients or any insurance 
company takes care of patients. I believe it is the physicians 
the nurses that do that, and I have never, when I had a concern 
about my patients, said, gee, I wonder what an insurance 
representative would say?
    I challenge any doctor here--have you ever had help from an 
insurance company, stopping bleeding, setting a fracture, 
treating a cancer, an infection or an inflammatory disease?
    Those of you who are not doctors or patients, have you ever 
been sick and said, gee, I hope there is an insurance agent who 
can help me with this fever?
    Senator Whitehouse. For the record, I have never seen an 
ambulance in Rhode Island go to an insurance office.
    Dr. Welch. Thank you.
    In October 2013, we received a letter from UnitedHealth 
plan informing me that we had been terminated, effective 
February 2014 from the UnitedHealth plan Medicare Advantage 
program. We were informed this was by virtue of a contract that 
permitted termination without cause with 90 days' notice.
    We requested information regarding the metrics that had 
been used to decide who was terminated. This request was denied 
on the basis that the information was proprietary.
    Our appeal was held by a phone conversation with two 
UnitedHealth plan medical directors--UnitedHealth plan medical 
directors--on December 5th, 2013. Only one question was raised 
for discussion--did we feel that we were properly and legally 
notified?
    We said, no, on the basis of many mistakes that had been in 
correspondence that was mailed to us regarding confusing us 
with other practices, et cetera.
    In any case, our appeal was denied.
    UnitedHealth plan has publically stated that their 
intention in contracting their Medicare Advantage network, by 
eliminating approximately one-third of Rhode Island doctors, is 
to improve quality while lowering costs. No data has been 
released describing how eliminating some of the finest doctors 
in Rhode Island will improve quality. I can only speculate how 
contracting the network will lower UnitedHealth's costs by 
increasing their profits.
    I would like to share with you who my patients are that are 
affected by this termination. These are the same generation as 
our parents or, as some of us get older, our siblings. They are 
the veterans of three wars.
    Ninety-four percent of my affected patients are skin cancer 
or pre-cancer patients, most of whom have had multiple skin 
cancers. One is a heart transplant who has had 164 separate 
skin cancers. Another saw four of her doctors, including myself 
and a cardiologist, terminated.
    One patient, 88 years old and a survivor of 8 skin cancers 
in the last 13 years, kept asking, what do I do now, as I 
excised yet another squamous cell carcinoma from his chest. 
What do I do now?
    Some of my patients are simply too old to understand what 
is happening to them. I dare say my mother, who is forgetful 
but not demented, would struggle with this.
    Some clearly did not understand that there was a time 
deadline to change their insurance.
    Some have told us they assumed that since there was no 
rational reason given for my termination that our appeal would 
be successful.
    Since the termination, the State of Rhode Island and 
UnitedHealth plan cut a separate deal for the retirees. 
Patients will be allowed to see their terminated doctors as 
long as those doctors agree to accept the out-of-network fee 
schedule.
    UnitedHealth is already our lowest payer and actually, for 
their MA plan, discount their payments to doctors. We expect 
the out-of-network fee schedule to be even further reduced. 
Nonetheless, we will accept the out-of-network fee.
    This accounts for about one-half of our UnitedHealth 
Medicare Advantage patients.
    About one-half of the remaining patients have switched 
their insurance to other carriers rather than lose their 
doctors, including the patient who stood to lose all four of 
her doctors and the heart transplant patient. This passes the 
burden of their obviously expensive skin cancer care to the new 
insurer and relieves UnitedHealth plan of this cost.
    These people have to be taken care of. The cost is the same 
no matter who delivers it unless they get inadequate care or 
simply fail to find another doctor.
    One of our patients switched back to traditional Medicare 
A/B with UnitedHealth, Medigap or supplemental insurance. Due 
to her skin cancer history, she saw her monthly costs double.
    The remaining patients have stayed with UHP. Some are too 
old to understand what has happened to them. Some are in 
employer-provided retiree plans with no choice and cannot 
change.
    A review of the dermatology providers UHP lists as 
available includes a doctor who is dead, doctors who have 
retired, doctors who have left the state, a doctor who is an 
internist and has no credentials in dermatology, doctors who 
are part-time or not seeing new patients. One of the doctors is 
me under an old EIN number and at an address I left 10 years 
ago in Providence.
    Apparently, the doctor that----
    Senator Whitehouse. If you move back, do you think you 
would get coverage?
    Dr. Welch. I do not know because I think in order to 
qualify I have to continue to not see patients.
    Most of the private practice dermatologists in Rhode Island 
have been terminated, including several of our finest 
dermatologists. I will back this statement up if anybody wants 
to talk to me later. I will give you names and credentials.
    We have been told that UnitedHealth plan is telling 
Medicare Advantage patients with no out-of-network coverage, 
that if they try three times and cannot find another 
dermatologist, then UnitedHealth plan may issue a letter that 
allows the patient to continue with us for a given period of 
time. This suggests that UnitedHealth plan realizes they do not 
have enough dermatologists to cover the loss of terminated 
dermatologists.
    In summary, UHP has not improved quality by terminating 
about one-third of the dermatologists in Rhode Island--and, by 
the way, this goes for other specialties as well--particularly 
since the availability of qualified replacements in adequate 
numbers is questionable.
    In fact, being forced to switch from providers such as 
myself, who were intimately familiar with their cases, to new 
providers may delay care. In the case of my patients, this 
means delayed diagnosis and treatment of skin cancer with 
increased morbidity, suffering and death for elderly patients.
    It would appear that UnitedHealth may lower their own costs 
by passing on the costs of care for their more expensive 
patients to other insurance carriers or by paying terminated 
providers less to care for state retirees or by charging 
patients who switch to their supplemental Medicare plan an 
increased premium.
    On my oath, I have sworn to serve the highest interests of 
my patients through the practice of my science and my art and 
that I will be an advocate for patients in need and strive for 
justice in the care of the sick. This is why I am here today, 
and I hope you will join me in defending our elderly patients' 
right to the best quality health care.
    Thank you for allowing me to speak before this Committee, 
and I will try to answer any questions.
    Senator Blumenthal. Thank you, Dr. Welch.
    I am going to turn first to Senator Whitehouse for his 
questions.
    Senator Whitehouse. Thank you very much, Chairman 
Blumenthal.
    Let me thank all of the witnesses for their testimony. I 
thought it was a particularly helpful and instructive hearing.
    What I extract from it is the conclusion that there are 
really three problems going on all at once in the middle of 
this.
    One is a consumer protection problem, and that is that 
people are being subjected to a lot of potentially unfair 
treatment, a lot of confusion, a lot of anxiety, problems of 
due notice and, of course, the nuisance of having to 
accommodate by finding a new provider who may not be the one 
you are comfortable with. All of that creates, I think, a 
significant consumer protection issue.
    Unfortunately, it is a consumer protection problem that 
falls most heavily on those who are sickest because it is for 
them that the anxiety and that the change will be the greatest. 
If you are healthy through all this and you never see a doctor, 
it is kind of an abstract problem that you have to face, but, 
when you are in the throes of a real illness, this is where it 
hurts you.
    It is not only a consumer protection problem. It is a 
consumer protection problem that has a particular burden for 
those who are the most ill and the most vulnerable, so I think 
that is a very real concern.
    The second problem is the problem of Medicare gamesmanship. 
As Ms. Stein mentioned, Medicare Advantage was supposed to 
compete head to head with Medicare and that she promised that 
it would be less expensive than Medicare when they fought for 
the right to compete head to head with Medicare, and by the 
time we passed the Affordable Care Act in Congress, they were 
14 percent above Medicare. They were being paid a premium when 
they said they could do it at a discount.
    The Affordable Care Act gets rid of that premium, and that 
may enhance the incentive that private carriers have to cherry-
pick the Medicare population, to try to make sure that the 
seniors who are golfing every weekend are the ones that they 
get and the ones who are in the hospital all the time are the 
ones that Medicare gets.
    That would be consistent with a recurring problem that we 
are seeing in the American corporate world, which is an effort 
to privatize profits and socialize costs and use their power in 
government to take advantage of the general public for their 
own purposes, so you see it in a whole array of different 
areas, but it is certainly an acute problem here.
    When you see the way this is done, there is at least a flag 
of suspicion up that they are doing this in order to dump 
expensive patients and to cherry-pick their patient mix and 
move expensive patients to Medicare and be able to make more 
money off of the population that they reserve.
    Until that concern has been rebutted, I think it stands 
plainly as a logical concern.
    The third is--and Senator Blumenthal, Senator Murphy and I 
are all keenly working on this--you know, we have got one of 
the most expensive health care systems in the world. Actually, 
we have the most expensive health care system in the world by a 
margin of about 50 percent above the second most expensive 
health care system in the world, which I think right now is 
Switzerland.
    Doing something about that cost problem is vital. One of 
the tools to do something about that cost problem is a well-
managed network, a good network, a high-value network, to use 
Ms. Kanwit's phrase.
    High-value networks can lower cost. High-value networks are 
measured by good outcomes produced by the doctors in the 
network, good electronic health record information technology 
in the network, good--what would you call it--coordination of 
care and handling of patients between doctors and specialists 
in the network and providing the very best care and not 
unnecessary care and eliminating errors and all that kind of 
stuff. All of that is very much worth doing.
    There is a final problem here, which is that when an 
insurance company chooses to use its network for a bad purpose, 
for the purpose of cherry-picking, for the purpose of shoving 
expensive patients over to Medicare and keeping the less 
expensive ones for itself--which remains, as I said, an 
unrebutted proposition here in this hearing because United 
would not show up--there is an opportunity cost.
    You cannot have a network that is at once designed to dump 
your more expensive patients and at the same time is designed 
to be the high-value network that should be the goal of our 
system. You make a choice. You cannot choose both. It is one or 
the other.
    When you choose the path that United appears to have 
chosen, you are foregoing the path of a responsible high-value 
network, and that should be of concern to all of us.
    I really do not have any questions so much as to get your 
feedback on whether you think I have properly extracted the 
three harms that are at issue here, and, in my view, there has 
been no testimony to rebut at this point the, I guess, default 
proposition that United is behaving in exactly those ways.
    Ms. Kanwit. Senator, if I may, I cannot speak to United 
where AHIP was not directly involved in that, clearly, but I 
would like to talk about two of the issues you raised.
    I appreciate your nod to high-value networks because we, 
too, at AHIP think that is the way--we think it is the way to 
go in the future to get our costs under control and our quality 
up.
    On the consumer protection problem, our testimony covers, 
but there is more information.
    CMS has extensive, extensive rules, actually consistent 
with some of Ms. Stein's suggestions, which allow for both 
adequacy of care and continuity of care--adequacy being that 
the network, the MA network, must have providers both in a 
geographical sense and in a quantity sense, enough specialists, 
enough PCPs, primary care providers, to make access easy for 
that particular beneficiary.
    There is that adequacy thing and then coupled with the 
continuity of care provision, which is also enshrined in our 
code of Federal regulations, which CMS administers, talking 
about what happens when a beneficiary either cannot get 
adequate care within a network. That beneficiary can get out-
of-network care at the in-network price if he or she needs, for 
example, a specialized oncologist somewhere, so those issues 
are there on the continuity.
    If there are network changes, which there will inevitably 
be--and CMS, as a matter of fact, wisely, Senator, wants to 
keep flexibility so that health plans in the MA space can do 
innovations. That is one of the points of MA, but that 
flexibility----
    Senator Whitehouse. I will concede to you that there are 
CMS rules that help protect against some of the worst possible 
consumer protections, but I hope you will concede that the 
testimony we have heard today shows that for a lot of consumers 
this choice by United has been a very anxious-making, 
discouraging, inconveniencing and, in some cases, potentially 
even care-threatening or compromising occasion.
    Ms. Kanwit. I do not have the facts to opine on that, to be 
honest with you. I have not followed it, and I just know what 
is in the public wheel and the conversation here this morning.
    Senator Whitehouse. Okay.
    Ms. Kanwit. I do think that there are consumer choices out 
there, if I could point out quickly.
    For example, there are 12 MA plans, as Professor Biles has 
talked about the other consumer choices. There are about 12 
other MA plans in the State of Connecticut, and those plans, in 
turn, have different benefit designs that a consumer could 
choose.
    In Rhode Island, there are five MA plans that a consumer 
could also go to.
    Senator Whitehouse. But you agree that the number of plans 
that is available does not cure a problem of short notice or 
notice that somebody does not really, you know, experience the 
problem until they have signed up and then the problem 
detonates and they go to their doctor for the first time six 
months later and he says, by the way, I am not in the network 
any longer.
    I think those are consumer protection problems that are not 
solved by the existence of other networks because the person's 
choice was not either informed or prepared enough for them in 
order to be able to take advantage of the other networks.
    Ms. Stein. Senator, I would comment that the issue with 
network analysis--unfortunately, there had been a medical 
review process where there had been some oversight on the CMS 
side in the past, but that was streamlined so that it was 
simply a calculation of numbers and a list of names.
    As my colleague to my right here pointed out, some of those 
names were people who were dead or who moved out of the state 
or did not practice correctly.
    An insightful analysis is clearly required. Simply just 
saying, oh, yes, you know, there are 50 names, and this should 
take care of it, and they can handle everything you need; we 
have not checked with them; we do not know if they are alive, 
is not adequate.
    Senator Whitehouse. You would think very much that a high-
value network determination would pick up the deadness of a 
doctor.
    Ms. Kanwit. Absolutely.
    Ms. Stein. Further, it is my understanding that--I think 
quite audaciously, if I am correct--the Connecticut 
congressional delegation requested a list of the names of the 
doctors who were in that work still and those who were not and 
was unable to get that information.
    Whatever protections there are were clearly inadequate, and 
also, I think that this demonstrates perhaps an outlier 
activity; that is, it is unusual.
    United is--I think, you know, you have got Medicare, 
Medicaid and United. United, like, owns healthcare in this 
country.
    Senator Whitehouse. It is big.
    Ms. Stein. It is very dangerous, and it is branded by AARP, 
so people go to United.
    I had people say to me, well, I am not affected, right, 
because I am still with AARP, so, while there are protections, 
they clearly have been inadequate.
    The definition of an adequate network needs to be reviewed 
to make sure it really meets the needs of, first the 
beneficiaries and then the physicians.
    I can tell you as a breast cancer survivor, if you are in 
the midst of getting care, you do not have a fungible 
oncologist, a radiation oncologist, an infusion center. These 
things are not just going to one Wal-Mart or the other.
    I would urge a review of what protections did not work and 
what needs to be done to make them work.
    Certainly, this cannot be proprietary information. My 
office could not get the information, but, how can the United 
Connecticut delegation not get this information, and how can 
CMS and this Administration, which I know and love, have been 
so, I think, repeating--regurgitating, I think the doctor 
said--the statements that it meets the rules?
    Maybe it did, but it obviously shocks equity and good 
conscience, what has happened, which means the rules are 
inadequate.
    Senator Whitehouse. Well, thank you.
    Ms. Stein. We need to level the playing field with 
traditional Medicare.
    Senator Whitehouse. I am going to very shortly return to 
Rhode Island, which, in our neck of the woods, we think is a 
long drive from here. We think a drive from Providence to 
Newport is a long drive in Rhode Island; so, from Hartford, 
back.
    Let me take this opportunity to thank Chairman Blumenthal 
for holding this hearing. I really, truly do think it has been 
instructive.
    In addition to the individual cases, I really think that as 
we are looking forward at how we fix the health care system and 
solve the huge 50 percent extra cost burden that Americans 
forced to bear because of the inefficiencies in the cost 
system, we are really playing with fire, and our insurance 
companies are really playing with fire when they are messing 
around with networks.
    We had bad network behavior in the bad old HMO days, as you 
will remember and as a lot of Rhode Islanders still remember, 
when what got you into the network was cutting a special deal 
with the insurance company; it had nothing to do with the 
patient.
    Those were bad old days, and the HMO situation got so bad 
that Hollywood made movies about people who were, you know, the 
victims of that HMO mentality. Now we have to fight against 
that now that we have patient-centered and high-value networks 
that need to be done.
    If the whole process of pulling physician networks together 
gets made disreputable by behavior like this, it is going to be 
very hard to take the steps we really need to have to build the 
high-value networks that Ms. Kanwit spoke so eloquently about.
    There is a real carry-on cost to the health care system, 
and I think to all of us, if we do not get this right and if we 
do not take the kind of action that Senator Blumenthal is 
leading on.
    Again, my pleasure to be here, and I will excuse myself and 
thank my Connecticut colleagues for their hospitality today.
    Senator Blumenthal. Thank you, Senator Whitehouse. We wish 
you well on your long drive back to Rhode Island, and thank you 
so much for your leadership in this area.
    I might just say since we had on this panel two former 
attorneys general, as well as two former United States 
attorneys, part of this problem strikes me as enforcement. You 
know, what Senator Whitehouse referred to as the flag of 
suspicion--I think it is more like a cannon burst so far as 
possible illegality here is concerned.
    After all, a court has found that United Healthcare Group 
very probably broke the law and, therefore, has enjoined its 
abusive action.
    I guess I want to pick up on what Judith Stein emphasized 
and others have alluded to--why isn't there better Federal 
enforcement in this area?
    Most people, as you remarked, do not know what CMS means, 
what those initials stand for and what its role or 
responsibility is.
    There are really two elephants in this room. One is United 
Healthcare, and the other is CMS and why it has not taken more 
effective action.
    I just to confirm what Ms. Stein said. In fact, the 
Connecticut delegation sought this information from United 
Healthcare, and they were unwilling to provide it.
    Let me open that question to all of you, having observed 
for a long time Federal enforcement efforts in this area, and 
let's turn the light on CMS and other agencies that have a 
responsibility.
    Dr. Biles. Senator, I think my response would be you are 
exactly right, and part of that, of course, is both the number 
and the expertise of the individuals in CMS responsible for 
managing what is now a $120-plus billion a year program.
    I think CMS has, of course, many responsibilities--
hospitals, physicians--across the board. I think in terms of 
the numbers and maybe particularly the focus in this area, I 
would say, has been lacking.
    I know in our case we are interested in data, being 
researchers. If we look at the Federal center that provides 
data, they have over 100 databases with physicians, hospitals, 
prescription drugs. There is not a single database that has 
been released on the Medicare Advantage program.
    Beyond that, again, just issue by issue--and I think Judy 
could comment--they have just been very reluctant to view this 
as a kind of Federal program with the sort of transparency that 
one would expect in a Federal program.
    Ms. Kanwit. Let me also say that, to come to the defense of 
CMS, they have had these regulations in place, our plans work 
hard to comply with them, Senator, and that the regulations--
that CMS wants the plans to have the flexibility in Medicare 
Advantage to make innovations that are not possible in the 
Medicare fee-for-service system.
    As Senator Whitehouse so eloquently said, we need to move 
away from the rigidified--the disjointed--Medicare fee-for-
service system to a much more collaborative and communicative 
thing with doctors and hospitals and health plans all working 
together to get health care costs down.
    Medicare Advantage was supposed to be innovative. It was 
supposed to provide benefits. Hence, it is a little more costly 
although not always.
    Medicare Advantage--actually, Medicare Advantage 
beneficiaries in many cases are two percent lower in local 
markets--the premiums--than fee-for-service. Two percent lower.
    It is not always--and it is not comparing apples to 
comparing if you compare fee-for-service, with all due respect 
to Ms. Stein, to Medicare Advantage because the Medicare 
Advantage has so many more benefits tacked on than the Medicare 
fee-for-service.
    Senator Blumenthal. I understand your point in the 
abstract, and you are right that Senator Whitehouse was very 
powerful and eloquent in describing the dynamic of what is 
supposed to be occurring.
    What we have here is 61,000 patients whose health care was 
severely jeopardized. They were put through the emotional 
wringer, not to mention the possible detrimental effect to 
their health care of, at the very least, opaque and abrupt 
treatment by United Healthcare, not only in Connecticut but in 
Rhode Island, in Ohio, in Florida, across the country. It was 
not an aberrant occurrence here.
    In Connecticut, the medical society went to court, and I 
joined them, not because I have any legal standing--in fact, I 
do not--but I was representing the interests of those patients. 
They were representing the doctors.
    I think the question can be legitimately asked--where was 
CMS?
    If CMS felt it did not have the resources or the authority, 
don't we need to do something about that enforcement gap?
    Obviously, I appreciate your coming to their defense, but I 
do not mean that you are personally responsible to answer the 
question.
    Ms. Kanwit. No, I am speaking generally for the Medicare 
Advantage program, Senator, and the advantages it brings to 
beneficiaries who are very, very happy generally. Over 90 
percent, I mentioned, happiness rates and satisfied rates with 
the Medicare Advantage program.
    CMS also has come out with statements in this particular 
case, the United case--again, I do not speak for United----
    Senator Blumenthal. Thank you.
    Ms. Kanwit. [continuing]. Talking about the open enrollment 
periods, et cetera, one of which we are in the middle of right 
now, until February 14th.
    Senator Blumenthal. Let me turn to the other witnesses who 
may have some response to the question I have raised.
    Dr. Saffir. Well, we were going to comment that in terms of 
communication, obviously, this is an example where 
communication was not well done, so that enhanced value of 
communication did not clearly not occur in this situation.
    We did try to reach out to United to get answers. I know 
that you sent letters. The delegation sent letters.
    The attorney general sent letters, and did not get answers.
    We did send requests out to CMS and got answers that were 
less than satisfactory, and those examples are available, and I 
am sure have been submitted as part of the paperwork and 
information for this hearing, so that was not satisfactory.
    I think that the network analysis needs to have better 
review. Like I said, United had a medical advisory panel that 
was unaware of this process. They should have been engaged. 
When you make a medical adequacy decision, it makes sense to 
have doctors involved.
    In terms of deciding how to best manage costs, I mean, your 
brother published an article in the New England Journal that 
talked about these costs and ways to look at it. It cannot be 
done working with just bureaucrats since it involves the health 
care of patients. You have to have doctors involved.
    Ms. Stein. Senator, when Medicare Advantage came into 
effect in 2003, there was, in fact, the movement to privatize 
Medicare happened. It did not happen with Social Security, but 
it happened with Medicare and, to me, shockingly, to the extent 
of taxpayers and all Medicare beneficiaries paying a huge 
amount more in order to do that.
    It is true that the law, I think, needs to be reviewed 
because there was a sense that this was not always state 
action--and I know you know what I mean by that--but these were 
private entities and that, yes, the government was not 
intertwined in the way it is with the traditional Medicare 
program.
    These private entities receive huge amounts, as you know, 
of public dollars in a way that is actually partly responsible 
for the alleged bankrupting of the Medicare program. United is 
not entitled to be a Medicare Advantage plan, and somehow the 
American people have misunderstood, have not been heard enough, 
of what we are paying, what it is costing us, to have private 
insurance plans be part of Medicare.
    I suspect that AHIP--I do not know--is as sorry as any of 
us that United did what it did because it is creating a huge 
problem for the good guys in the system, but they are the 
biggest guy, or one of the biggest guys.
    We have to make sure that the laws that were put into 
effect, largely as a consequence of the law that was passed in 
2003 and the regs that followed, which were at the time very 
much intended to move people to Medicare Advantage--and that 
happened.
    It used to be you could move back from traditional Medicare 
to Medicare Advantage at this time. This Administration 
switched that. The philosophy switched. The implementation and 
the regs have not caught up.
    If from this hearing we actually could believe that we 
would look at the regs to see if they meet this kind of 
circumstance, when in fact the clever notion to deal with the 
doctors and that removes the sick patients--clever, I say in a 
negative way--shows us how much can happen under the current 
regs.
    We need to make sure that the burden is on the plan to show 
that what it has done is to lead to innovation, good 
flexibility, true coordination of care and more services, not 
$75 toward eyeglasses, not a health club membership, but all 
those things that the MA plans and their industry always want 
to tell us. The burden should be on the plan to show that value 
is really happening.
    I can tell you I am one of the few attorneys who represents 
Medicare beneficiaries as my career. It has yet to be shown to 
me. We were told that in Medicare+Choice, and we have been told 
that in Medicare Advantage.
    This whole country is paying dearly for what is not good 
flexibility. This kind of flexibility is terrible. Medicare 
could not get away with it.
    What is innovation?
    What is coordinated care?
    What real more services are being offered?
    I think those regs and the burden of showing that needs to 
be really reviewed.
    Ms. Kanwit. Senator, may I just quickly respond?
    Yes, two quick points to Ms. Stein's questions.
    On the quality issue, the data out there--and these are not 
AHIP's data; they are in respected publications, like Health 
Affairs, and we cite them in page three of our testimony--show 
the huge quality differences: 17 percent, 20 percent for breast 
cancer, diabetes, cardiovascular disease, et cetera, in 
Medicare Advantage plans, so there are demonstrable quality 
differences.
    I also cannot let go unanswered Ms. Stein's impassioned 
plea on the alleged motives for the network changes that 
United, or anyone else, ever makes in the Medicare Advantage 
plan. There is really no incentive for an MA carrier to plan to 
cherry-pick, as Senator Whitehouse talked about.
    All of it is risk-adjusted. The premiums that the plan gets 
are risk-adjusted by CMS, so it does not--the plan can take on 
a person with six chronic illnesses versus a person who is 
playing golf every day and not be hurt financially.
    There is also guaranteed issue in Medicare Advantage. 
Anyone can sign up--whether you are healthy as a horse or have 
20 chronic diseases.
    The point is there is no particular incentive for plans to 
do that, so I just want to correct the record on that.
    Dr. Welch. May I speak?
    Senator Blumenthal. Of course, Dr. Welch.
    Dr. Welch. Thank you.
    Blue Cross-Blue Shield of Rhode Island has taken on--is it 
8,500--8,500 more patients as a result of this, patients who 
would not leave their doctors.
    As I pointed out, my patients are skin cancer patients. 
They need a lot of procedures that are expensive, so those 
patients are no longer part of United Health's risk pool.
    In addition, they discount the fees that they pay to us 
below what Medicare pays.
    Now, just so everybody understands, the way that the 
Medicare fees are arrived at--there is a panel of doctors 
called the RUC panel which makes recommendations across 
specialties. These are considered by the government--CMS, I 
believe--and then relative values, procedures and services are 
assigned that are felt to be fair and equitable.
    United Health, to get these efficiencies, discounts those. 
They then charge the patient a $40 co-pay, so, for a $45 
service, that means the patient pays $40, United Health pays 
$5, and the doctor discounts his services.
    I think that there is financial incentive here.
    Another point that troubles me--you mentioned earlier that 
these--there is a phrase I need to have documented. I think the 
first word is value. Does anybody remember what that phrase is?
    Value? The panels have value?
    Ms. Kanwit. High-value provider networks.
    Dr. Welch. High-value provider networks, right.
    Oh, by the way, thank you for commenting. I admire your 
courage.
    One of the ways that you said that those high-value would 
be determined was through published metrics by a which a doctor 
could be determined to be providing good quality care, 
something like that. Maybe I am paraphrasing you.
    Ms. Kanwit. No, that is accurate.
    Dr. Welch. Okay. Well, let's suppose those are there.
    I will, to you, lay out my credentials, my 33 years of 
experience, my record in taking care of patients, my honors and 
awards. I will lay that out.
    United Health will not tell us the metrics upon which we 
were judged nor will they share their data.
    The importance of the data is there are mistakes in here--
bad providers.
    By the way, that dead dermatologist was excellent five or 
six years.
    They make mistakes, but we are not allowed to evaluate the 
data.
    I am confident that my quality and my skills would equal 
any dermatologist practicing in New England. I challenge you to 
show otherwise, publically, in any court you want--basketball, 
tennis, court of law. Prove it. Okay?
    Put your money up. Prove it.
    Otherwise, what you have done is you have taken a doctor 
who is devoted his career to caring for his patients and 
managing skin cancer away from those patients and said, go find 
another doctor.
    We are not widgets. We are not interchangeable parts. Some 
of us specialize in one thing. Some of us are interested in 
another. There are reasons that the doctors in Yale 
dermatology, by the way--who, I believe, were all terminated--
are ranked among the highest in the world.
    Forgive me. I told my wife I would not get passionate.
    Senator Blumenthal. Thank you, Dr. Welch.
    Dr. Welch. You are welcome, sir.
    Senator Blumenthal. Just for the record, because Ms. Stein 
mentioned it, I want to say United Health Group is, in fact, 
the largest Medicare Advantage provider, at least in 
Connecticut, with 43 percent, as I mentioned earlier--61,000. 
The next largest is Emblem Health, which has 32 percent and 
45,000. The next largest are Aetna with 16 percent; WellCare 
Health Plans, five percent; WellPoint, four percent.
    United Health Group is not just a small outlier. It is the 
major provider in Connecticut, and my guess is a major provider 
in those other states where similar kinds of opaque and abrupt 
actions have been taken.
    Dr. Saffir, did you have something?
    Dr. Saffir. You mentioned Emblem Health, and so I had the 
opportunity to get together with some of my colleagues in New 
York, and I am sure Senator Schumer was also paying attention 
to this, but Emblem Health had also considered doing some 
network changes, but, given the reaction and the, I guess, 
sloppy nature that United incurred, they decided to back off.
    It, again, leads me to believe that it was profit-based 
because if it was for the good of the patients and they backed 
off, then that is a sad mistake, but I think that they realized 
this opportunity to make their networks more profitable was not 
the time to be taken now.
    I think the example that United, as the large payer that it 
is, needs to be the example that we look at how we do this 
better. I think that is a clear example.
    I also say the regular Medicare program, for the amount of 
services it delivers, has been shown to be one of the most 
efficient in terms of the net medical loss ratio costs. What it 
provides versus its overhead expenses--what the CEOs, what the 
administrators, what everybody else gets--are not exorbitant in 
the regular Medicare system compared to what the salaries might 
be for some of the for-profit health plans.
    Ms. Stein. Yes, I think that is one of the things I would 
like to have. I keep being frustrated that people are not being 
told, at least in Connecticut, you can get back to traditional 
Medicare and see your physicians--speaking to your constituent.
    It is extraordinarily important for them to know that.
    Unfortunately, the way this system is stacked towards MA 
now, towards private Medicare, it means they have to pick up a 
Medigap plan, and in many states they cannot do that. In 
Connecticut, happily, we have extra protections, but it is 
expensive.
    That is part of the reason that we need to look at how can 
we level the playing field and then let the private market in 
if it can play according to the same rules, but do let people 
know that they can go back to traditional Medicare, and in 
Connecticut they can get, if they need, a Medigap plan.
    Senator Blumenthal. I will just tell you that my office has 
been dealing with tens, if not hundreds, of inquiries, trying 
to direct them in ways that can reassure them and restore the 
health care that they feel they need and deserve, and the kind 
of practical work that you are doing with your clients, I 
think, has been enormously valuable as well.
    Professor?
    Dr. Biles. Senator, I was just going to comment. Generally, 
as we have said, this is a national issue, and it is one that 
is likely to increase.
    I think a point that has just been made is that the five 
major plans--United, Kaiser, Humana, Blue Cross, WellPoint and 
Aetna--have more than 60 percent of the enrollees nationwide, 
so here we see a giant, out-of-state insurer, but that is not 
unique. That is the pattern primarily across the country.
    The lessons from here are not just for Connecticut but for 
the Nation.
    I think then back to the three points that Senator 
Whitehouse made; I think the advance notice by September 30th 
would make a big difference and particularly if the plans then 
interacted with their physicians earlier than that.
    They will complain they do not get their rates until 
September, but to use that an excuse not to make this sort of 
information available to beneficiaries during the self-
enrollment period, I think, is wrong.
    Secondly, CMS has never done very much in this physician 
network adequacy area, and, again, to some extent, when they 
are overpaid by----
    Senator Blumenthal. CMS--just for the record and for the 
understanding of everybody who is listening today, CMS actually 
has a legal responsibility in that area, does it not?
    Dr. Biles. Yes, but this is not an area, I think it is fair 
to say, particularly since these very substantial extra 
overpayments beginning in 2006 that really focused in this 
area.
    Again, as the payments ratchet down, this does become an 
area in which the individuals at CMS would need to create a 
whole new team and people to manage that.
    Then I think the third area is this whole risk adjustment 
and gaming, and I do think, on one hand, Medicare Advantage has 
the best risk adjustment system in the country. On the other 
hand, it requires plans to submit data, and you would guess 
that plans have resisted submitting more and more data, so I 
think that is a third area in which your kind of comments about 
CMS's diligence is probably appropriate.
    Ms. Kanwit. You know, MA plans, to the professor's 
comments, really want to make their beneficiaries happy. They 
want to do a good job. They want to follow CMS regulations. I 
do not know why they would resist producing data to CMS.
    We, at AHIP, just for example, Senator, have a really good 
working relationship with CMS. We talk to them all the time 
about issues related to this.
    They provide incredibly detailed oversight. They just 
proposed, actually just last week, additional rules in the Part 
C Medicare Advantage space, so they are looking at this with a 
fine-tooth comb.
    I think the regulation is particularly adequate and what we 
are discussing here today is how to move the American health 
care system, Senator Whitehouse said, into the 21st Century and 
couple cost efficiency and get the quality.
    One final point to the professor's comments--the real issue 
here is how many choices have, and it does not make any 
difference how big a particular plan or how small a particular 
plan is in the Medicare Advantage space, say, in Connecticut.
    What really counts is consumer choices. There are 12 
different MA carriers, MA plans, in Connecticut, and, as I 
mentioned, each of those plans have different permutations of 
those plans. You can have an HMO plan, a PPO plan, within MA, 
so consumers have a lot of different MA choices.
    Senator Blumenthal. Well, consumer choice is an 
extraordinarily valuable feature until there is bait and 
switch, and then consumers may choose but may find that their 
choices put them in a position they had not expected.
    I think there has been some of that here. Bait and switch 
is a fair way to characterize what the effect has been.
    In addition to egregiously deficient notice, I think there 
has been fairly common agreement--I do not want to speak for 
everyone--that the notice here left a lot to be desired.
    Remember, after patients were notified, they were also told 
that their physicians could appeal, and so they might remain in 
the network anyway, and they had a deadline to make decisions.
    Nobody can forgive them for being more than a little bit 
confused and anxious about the choices that they had under this 
system because they had no idea what the consequences of 
choices would be in addition to the complexity of the system.
    All of the permutations, you know, are a little bit like--I 
do not want to impugn another industry, but we all know the 
fine print that can often make choices more confusing or 
misleading or even deceptive.
    I think that this hearing has been enormously valuable, as 
Senator Whitehouse said, and your testimony will be a part of 
the record.
    I am going to close this part of the hearing at this point.
    You have been very, very helpful and cooperative.
    As long a journey as the Senators may think they had, some 
of you have come from much longer distances, and we truly 
appreciate it, including Rhode Island, Dr. Welch, and thank you 
very much for being here today.
    If you want to add anything to your statement, we are going 
to keep the record open for a week so that you can feel free to 
submit anything else in writing that you would like to do, and 
we will make that part of the record also, without any 
objection.
    Thank you very much.
    Ms. Kanwit. Thank you very much.
    Ms. Stein. Thank you, Senator.
    Senator Blumenthal. We will hear now from Mr. Buccieri if 
he is agreeable to doing so.
    By the way, while you are switching, I want to give a 
particular thanks to the staff of the Committee on Aging, who 
has been so helpful and cooperative.
    I also want to thank my staff for their excellent work. 
Rich and Laurel are here today. I think many of you have spoken 
to them and others on my staff who have been so helpful.
    Mr. Buccieri, I want to again thank you for being here 
today. Both your bravery and your eloquence are very much 
appreciated not only by myself but the Committee as a whole, 
and I want to really thank you for, again, sharing your story 
as you have with my staff and the public and just allow you to 
briefly summarize your experience with the Medicare Advantage 
plan in which you were enrolled.
    Mr. Buccieri. Thank you for the opportunity.
    My name is Robert Buccieri, B-u-c-c-i-e-r-i. I have been on 
United Healthcare Medicare Advantage plan for almost two years, 
and I think that they have done--thus far, it has been a great 
policy up until the fall when I started receiving one letter 
after another letter after another letter of cancellations--my 
nephrologist, the doctors at Yale Transplant, one by one, the 
medical group they belong to, as well as the dialysis center in 
Norwalk.
    It has been an emotional roller coaster, dealing with this, 
and I thank you and your staff for helping me along the way. We 
are not done, but I think we are making progress.
    I just wish that United Healthcare, even with their 
responses, was more definite instead of vague. In one letter I 
just got yesterday, it said I could see my doctor for 25 
minutes from like a 4-month period. I do not even understand 
what that means, and it is things like that.
    With the dialysis, even it is so many visits, but it is 
just difficult because even if I see my doctor and they give 
you a 90-day window, if it is not resolved in another 90 days, 
I have to do it all over again, and who knows what is going to 
happen at that point.
    Senator Blumenthal. I gather there was some emergency 
condition that required you to seek treatment immediately.
    Mr. Buccieri. Yes. Well, my doctors have been very good at 
stabilizing, but progression is very slow, and right now I am 
in stage five kidney disease, which I guess is called end-stage 
renal disease, and I am on the transplant list that, you know, 
they have in the hospital, and even just maybe a week ago I 
received a phone call from United Healthcare saying that maybe 
I could go to Boston or maybe I could go to New York. Who wants 
to go to New York or Boston when you have one of the best 
hospitals in the State of Connecticut?
    It is just things like that.
    Senator Blumenthal. These network changes have real-life 
practical consequences for your treatment--where it is done, by 
whom and so forth.
    Mr. Buccieri. Absolutely.
    Senator Blumenthal. Has Yale been helpful and cooperative--
Yale-New Haven?
    Mr. Buccieri. They have, and you know, people have been 
very good about helping, even the reps I have at my health 
care, but obviously, they are very limited to what they can do 
or what they can say, and I have asked for them to get things 
in writing, but even with that, it has not come through.
    Senator Blumenthal. Have you sought to contact United 
Healthcare?
    Mr. Buccieri. On many occasions. As I said, I guess my 
nurse liaison or nurse case manager for my health care is very 
good, and she has been calling the dialysis center because at 
one point she said that they signed a national contract, but my 
problem was--or my question was my nephrologist is the medical 
director of the dialysis unit. I said, how is that going to 
affect, or is that going to affect, the situation?
    She was unsure, and she called back and said that some are 
changing the doctors and using a different nephrologist.
    I have been with this doctor for, I guess, two years, and I 
have a very good rapport with him, and I want to continue that. 
I do not really want to start a new doctor.
    When they asked me that maybe I could go to New York or 
Boston, I said that is a possibility, but then you begin again 
at the bottom of the list, and here we go, you know, waiting 
another couple of years or who knows how long.
    Senator Blumenthal. You begin at the bottom of the list in 
terms of eligibility for the transplant.
    Mr. Buccieri. Yes.
    Senator Blumenthal. You begin with a new doctor whom you do 
not know, and you have to go to a place that is distant from 
where you live.
    Mr. Buccieri. Yes.
    Senator Blumenthal. All of those factors make it very, very 
difficult and different to receive health care under those 
terms.
    Mr. Buccieri. That is true.
    Senator Blumenthal. Is there anything else that you would 
like to add?
    I know that my staff has been very much engaged in seeking 
to help you, and we appreciate your cooperation in that effort, 
too.
    Mr. Buccieri. I appreciate the help, and your staff has 
been very helpful--Grady, in particular.
    I think the main thing--obviously, I would like to get the 
whole thing solved and get my doctor back, but if in fact they 
cannot, I would like to get some sort of notification in 
writing saying what I can do because even if they say I can see 
my doctor, how do I go to the doctor and tell them that I want 
to see someone out of network, but do not worry; they are going 
to get paid for it?
    You know, I think it is going to be very difficult.
    Senator Blumenthal. Well, thank you again for being here.
    Grady Keefe of my office and I are going to continue 
working with you and fighting for you.
    Again, we are very, very grateful--the whole Committee is--
for your attendance today and your participation. Thank you so 
much.
    Mr. Buccieri. Thank you for this opportunity and the help 
you have provided.
    Senator Blumenthal. Thank you.
    I am going to close the hearing.
    As I mentioned earlier, the record will stay open for one 
week in case any Committee members have questions for the 
witnesses or if the witnesses have additional submissions.
    With that, this hearing is adjourned. Thank you.
    [Whereupon, at 3:47 p.m., the Committee was adjourned.]



      
      
      
      
      
      
      
      
      
      
      
      
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                                APPENDIX

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                      Prepared Witness Statements

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                       Statements for the Record

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